Medicaid Managed Care 101: Building A Common Understanding For The .

Medicaid Managed Care 101: Building a Common Understanding for the Healthy Students, Promising Futures Learning Collaborative March 30, 2017 Lena O’Rourke, on behalf of Healthy Schools Campaign Ashley A. H. Gray, Institute for Medicaid Innovation Moderated by Alexandra Mays, Healthy Schools Campaign Managed Care 101

Learning Collaborative and Medicaid Managed Care Lena O’Rourke, on behalf of Healthy Schools Campaign Managed Care 101

Healthy Students, Promising Futures Learning Collaborative Healthy Students, Promising Futures Learning Collaborative was developed by: U.S. Department of Education (ED) U.S. Department of Health and Human Services (HHS) With support from Healthy Schools Campaign (HSC) and Trust for America’s Health (TFAH) Managed Care 101

13 Participating States California Colorado District of Columbia Massachusetts Minnesota Mississippi New Jersey New York Managed Care 101 Ohio South Carolina Tennessee Virginia Washington And growing .

Learning Collaborative Goals Increase access to school-based health services through: Developing and implementing state vision and strategies to scale up school-based Medicaid services Identifying and assessing the options for delivering health services in schools (school nurses, partnerships with providers such as hospitals, health centers, school-based health centers, mobile health, telehealth) Addressing barriers and leveraging new opportunities, including through ESSA Receiving technical assistance on delivery models, Medicaid reimbursement and policy opportunities from federal policymakers and national and state organizations Assessing opportunities for innovative partnerships Managed Care 101

Identifying Innovative Strategies Schools are considering a range of delivery and reimbursement models. Teams are considering: Delivery models including school nurses and other SISP, relationships with providers such as hospitals and health centers, school-based centers Identifying innovative models for expanding capacity such as telehealth How to serve specific student populations or students with high health care needs that impact learning The role and opportunities of managed care Managed Care 101

Medicaid, Managed Care, and Children More than 70% of Medicaid beneficiaries are enrolled in private managed care organizations (MCOs) Almost 9 of every 10 children enrolled in Medicaid and CHIP receive health care through a managed care arrangement 39 states rely on MCOs to cover all or some of their Medicaid beneficiaries (including all states in the Learning Collaborative) In 2015, 32 of the 39 Medicaid MCO states covered 75% or more children through MCOS Managed Care 101

Medicaid, Managed Care and Services The plans contract with the state to provide comprehensive services Plans are responsible for ensuring access to service through their provider networks Children in MCOs are guaranteed the full EPSDT benefit but some services may be covered by the MCO and others directly by the state Managed Care 101

Medicaid, Managed Care and Schools Millions of Medicaid-enrolled students are covered by MCOs Schools and school districts do work with MCOs in a number of innovative ways The potential for partnership is great Thoughtful analysis is needed to explore MCO partnerships Managed Care 101

Medicaid Managed Care 101 Ashley A. H. Gray, MPP Health Research Associate Institute for Medicaid Innovation

What is the Institute for Medicaid Innovation? The mission of the Institute for Medicaid Innovation, a 501(c)3 entity, is to improve the lives of Medicaid enrollees through the development, implementation, and diffusion of innovative and evidence-based models of care that promote quality, value, equity and the engagement of patients, families, and communities. The vision of the Institute for Medicaid Innovation is to provide independent, unbiased, nonpartisan information and analysis that informs Medicaid policy and improves the health of the nation. 11 I N S T I T U T E F O R M E D I C A I D I N N O V A T I O N

Medicaid Basics

What benefits are covered under Medicaid? Mandatory Items and Services Physicians services Laboratory and x-ray services Inpatient hospital services Outpatient hospital services Early and periodic screening, diagnostic, and treatment (EPSDT) services for individuals under 21 Family planning and supplies Federally-qualified health center (FQHC) services Rural health clinic services Nurse midwife services Certified nurse practitioner services Nursing facility (NF) services for individuals 21 or over 13 “Optional” Items and Services Prescription drugs Medical care or remedial care furnished by licensed practitioners Diagnostic, screening, preventive, and rehab services Clinic services Dental services, dentures Physical therapy Prosthetic devices, eyeglasses Primary care case management Inpatient/nursing facility services for individuals 65 and over in an institution for mental diseases (IMD) Inpatient psychiatric hospital services for individuals under age 21 Home health care services Respiratory care services for ventilator-dependent individuals Personal care services Private duty nursing services Hospice services

How does Medicaid work? The program guarantees coverage to individuals and federal financing (i.e., federal match) to states between 50-73 percent of costs for coverage, with no cap. States have authority to tailor their program to meet the needs of beneficiaries in their state, making state Medicaid agencies the right partner for the learning collaborative. States may administer Medicaid benefits themselves (i.e., fee-for-service (FFS)) or may contract with managed care organizations (MCOs) to manage and take on financial risk for services CMS Sets Guidelines Requiring States to: Implement programs statewide Provide comparable benefits to comparable employees Ensure freedom of choice of provider Cover mandatory services Cover mandatory populations I N S T I T U T E F O R States Have Flexibility to Set: Eligibility standards Benefits package Payment rates Program administration Provider certification M E D I C A I D 14 I N N O V A T I O N

Medicaid Managed Care

A Closer Look at Fee-for-Service and Managed Care Fee-for-Service (FFS) Managed Care Organizations (MCOs) Care coordination is not provided by the state. Care coordination is provided by the managed care organization (MCO). Payments to providers are based on volume of patients seen and services received – not quality or outcomes. MCOs are paid an established capitation rate for each member within a specified group (e.g., pregnant women, children with intellectual disabilities) from the state. MCOs must operate within the rates provided by the state, managing risk and the health of their members to improve health outcomes and quality of care. Payments are also tied to quality and value. Health plans face financial consequences for: oPatient non-compliance oPoor quality outcomes oUnnecessary utilization oPoor patient satisfaction Payments are set in the physician fee schedule, identified by the state Medicaid agency. It is very unlikely that a provider would receive reduced payment due to: oPatient non-compliance oPoor quality outcomes oUnnecessary utilization oPoor patient satisfaction Claims are submitted by providers directly to the state. The state then pays providers, per the physician fee schedule. Claims are submitted by providers directly to the MCO. The MCO then pays providers, per the negotiated contracts with providers. 16 I N S T I T U T E F O R M E D I C A I D I N N O V A T I O N

Enrollment in Medicaid MCOs has Grown to 73 percent of all Medicaid Enrollees in 2016 Source: Avalere analysis of CMS Medicaid Managed Care Enrollment Reports, 1997-2011. I N S T I T U T E F O R 17 M E D I C A I D I N N O V A T I O N

What are the goals of MCOs? MCOs function and operate very similarly to commercial insurers, or those offering employersponsored insurance. Prevention Shift services from treatment to prevention focus, keeping members out of emergency rooms, and reduce/eliminate in-patient stays and urgent care visits. Focus on targeted case management of chronic conditions. Integration of behavioral health with medical care. Quality Providers Providers deliver high-quality care and are incentivized to manage utilization. Strengthening primary care providers and centralizing care in a medical home model. Receive accurate and detailed billing information from providers and facilities. Appropriate Services and Facilities Care must be medically necessary and appropriate for each patient’s condition. Care must be provided by the right provider, in the most appropriate setting. (Meet beneficiaries where they are. For example, school based health centers.) 18 I N S T I T U T E F O R M E D I C A I D I N N O V A T I O N

How do MCOs interact with different players? State Establish contracts Identify quality improvement and performance improvement projects when needed Negotiate capitation rates Assignment of Medicaid enrollees to MCOs Report claims and quality data Members Enrollment Health risk assessment Identify unmet medical needs Care coordination Targeted case management Disease management Social supports Quality monitoring Track patient satisfaction Providers and Facilities Contracting and credentialing Negotiate payment rates Offer clinical guidelines Data mining and member reports to target and perform risk stratification and identify unmet medical needs Pay claims Quality monitoring Track provider satisfaction 19 I N S T I T U T E F O R M E D I C A I D I N N O V A T I O N

MCO Contracting Basics

What factors do MCOs consider when contracting with providers? MCO contract requirement to devise and implement a performance improvement project. Gaps in service delivery and service delivery coordination. Innovative and creative alternatives to enrich traditional services. Integration of member/family voice in planning, evaluation, and delivery of service. 21 I N S T I T U T E F O R M E D I C A I D I N N O V A T I O N

What do MCOs need from their network participants? High quality services that are also compliant with state and federal regulatory requirements. Services that achieve positive, measurable results that improve quality of care and health outcomes and reduce gaps in care. Examples of measurable results include increased completed health risk assessments, increased preventive screenings, increased medication adherence, reduced emergency department use. Support health care affordability principles and result in a cost effective approach to services. Consider return-on-investment. Can partnering with your organization result in reduced costs and increased health outcomes/positive results? 22 I N S T I T U T E F O R M E D I C A I D I N N O V A T I O N

What does the MCO contracting process look like? Confirm the MCO’s network needs. (What providers/facilities are needed in the MCO’s network?) Reach out directly to MCO to discuss unmet needs Complete application and paperwork necessary to participate. Learn relevant credentialing criteria. The MCO may be able to assist with this process. Participate in contract negotiation process. Maintain copies of all paperwork including welcome letter and signed/executed agreement. Participate in provider trainings/forums. Obtain copies of the MCO’s provider handbooks (usually posted on website). 23 I N S T I T U T E F O R M E D I C A I D I N N O V A T I O N